In a Heartbeat: C A L I FOR N I A New Resuscitation Protocol Expands EMS Options H EALTH C ARE F OU NDATION Introduction Los Angeles (UCLA). Previous policy had allowed Emergency Medical Services (EMS) personnel paramedics to forego attempted resuscitation (paramedics) are usually the first trained providers only if presented with a written DNR, or if there to make a decision about attempting resuscitation were obvious signs of irreversible death.5 The new for people who experience cardiac arrest other than policy permits paramedics to forego attempted Issue Brief in a hospital.1 Over the past several decades, the resuscitation in two additional circumstances: availability and use of techniques and equipment ◾◾ A family member on the scene verbally for defibrillation, intravenous life support requests DNR in accordance with patient medication, and intubation have contributed wishes but without a DNR document; or to resuscitation becoming the default mode of response to cardiac arrest in the field. This nearly ◾◾ A patient is found in asystole (without any universal practice of attempted resuscitation, cardiac electrical activity) and at least ten however, does not fully align with patient and minutes have elapsed between patient collapse family preferences, with paramedics’ own clinical and initiation of CPR. judgment, or with best medical practice. Many patients wish to forego resuscitation but their The present study tracked EMS responses to choice is not recorded in a formal Do Not nontraumatic cardiac arrests before and after Resuscitate document (DNR) or other health care implementation of LAC’s new policy. The results directive.2 Even when a DNR exists, frequently showed a small but meaningful reduction in the it is not produced when paramedics respond rate at which paramedics attempted resuscitation to a cardiac arrest emergency. Further, patients in the field, especially when a family request was with a heart rhythm that does not respond to made to forgo resuscitative measures. Also, EMS electroshock treatment and/or who do not receive personnel who worked under the new policy timely cardiopulmonary resuscitation (CPR) reported, in focus groups, their considerable are highly unlikely to survive neurologically satisfaction with the new policy guidelines. Almost intact,3 and almost all patients would not want all paramedics felt freer to solicit and act on to be resuscitated to a state of severe neurologic family preferences, and were more comfortable impairment.4 with the circumstances under which they were allowed to forego resuscitation. Important, too, In an attempt to permit paramedics to make was the fact that the new policy was implemented cardiac arrest resuscitation decisions more without any reports by family members of adverse congruent with patient wishes and the likelihood consequences attributable to the new policy. (For of neurologically intact survival, in July 2007 an explanation of the study’s methodology, see the Los Angeles County (LAC) EMS system Appendix A.) implemented a new resuscitation policy developed in partnership with the University of California, A pril 2010 Los Angeles County EMS Change in arrest cases (53 percent of these being verbal requests) Resuscitation Policy during a control period, compared to 5.3 percent among agencies that did not recognize verbal requests.7 Notable LAC’s Previous Resuscitation Policy in the King County policy change is that 90 percent of Before implementation of its new policy in July 2007, EMS personnel found the decision to forego resuscitation the LAC EMS system permitted paramedics to forego to be simple and straightforward in most cases. Similarly, resuscitation in nontraumatic cardiac arrest responses only in southeastern Ontario, Canada, where the policy under two conditions: (1) obvious signs of irreversible now permits recognition of verbal DNR requests, a death (e.g., rigor mortis or decomposition); or (2) the large majority of both paramedics and the family DNR presence of a valid written DNR or other valid written decision-makers are reported to be comfortable with this advance health care directive with instructions not to process.8 resuscitate. While almost all patients would not want to be resuscitated to a state of severe neurological impairment, an evaluation of a six-month period of POLST Adds Another DNR Document EMS responses under the previous policy revealed that On January 1, 2009, subsequent to this study of the new LAC policy, the Physician Orders for Life-Sustaining only 6 percent of patients had a valid written DNR, Treatment (POLST) law became effective in California.* and that even of these almost 20 percent underwent POLST is a standardized form medical order, attempted resuscitation because the written DNR was documenting patient wishes for treatment, signed by unavailable.6 The same evaluation also indicated that a both the patient and physician. A POLST form is more comprehensive than a pre-hospital DNR, and can include majority of these cardiac arrest cases occur in the home, decisions about whether to: with a family member present 29 percent of the time and • Attempt cardiopulmonary resuscitation; someone familiar with the patient’s medical history (likely • Administer antibiotics and intravenous fluids; and family, but not specifically identified as such) present an • Use intubation and mechanical ventilation. additional 52 percent of the time. The combination of POLST is recognized throughout the state medical these results led to the conclusion that in many cases a system, transfers with the patient from one care family member might be able to verbally communicate setting to another, and must be honored wherever it is to EMS personnel a patient’s DNR preference, which the presented. POLST law provides immunity from civil or paramedic could then act upon given the proper clinical criminal liability to health care professionals who comply in good faith with a patient’s POLST requests. POLST circumstances. thus gives EMS providers another basis on which to honor patient wishes regarding attempted resuscitation. Policies Elsewhere that Permit Forgoing *California Probate Code §4780 et seq. The POLST form has been Resuscitation Based on Verbal DNR Request approved by the California Emergency Medical Services Authority, effective January 1, 2009. The notion of changing LAC policy to permit recognition of verbal family DNR instructions was supported by similar policies in at least two other EMS systems in the United States and Canada. In King County, The New LAC Resuscitation Policy Washington, EMS personnel may forego resuscitation Based on the potential for family members to express if a family member makes a verbal DNR request and it the DNR wishes of a cardiac arrest patient in many is clear to the paramedic that the patient is “terminally circumstances, and on the success of the verbal DNR ill.” Implementing this policy, King County paramedics policies in Washington and Ontario, the LAC EMS decided to forego resuscitation in 11.8 percent of cardiac system partnered with UCLA researchers to develop a 2  |  California HealthCare Foundation change in its policy and in the practice of its paramedics. was limited by researchers’ lack of direct access to the The new policy, which went into effect July 1, 2007 families involved. following a period of training for all EMS field personnel, permits paramedics to forego resuscitation attempts under Quantitative Changes Under the New Policy either of the following conditions: One of the assumptions underlying the LAC policy change was that rates of attempted resuscitation would ◾◾ If an immediate family member on the scene verbally fall somewhat, both from an increase in family-expressed requests it and no other family member objects; or DNR decisions and from the number of patients on ◾◾ If the patient has clinical characteristics that preclude whom resuscitation would not be attempted under the the likelihood of survival without severe neurological new clinical criteria guidelines. The results bore out this impairment. These characteristics are defined in assumption, though after the policy change there was also the policy as asystole (lack of any cardiac electrical an unanticipated change in reporting of those with signs activity) plus more than ten minutes from patient of irreversible death. collapse to either bystander CPR or EMS-initiated basic life support measures. (For the complete text In those patients without signs of irreversible death, of the policy, see Appendix B; the new elements are forgoing attempted resuscitation was modestly but found in the policy’s Section I, Parts C3 and C5.) significantly more likely under the new policy: 8.5 percent pre-change versus 13.3 percent post-change. When patients with signs of irreversible death were No Harm Reported Under the New Policy removed from the analysis, the rate change in attempted Balanced against the positive quantitative and qualitative resuscitation was smaller, from 82.9 percent to results from the change in the LAC EMS resuscitation policy must be any reported negative consequences. 79.3 percent. After adjusting for patient demographics During the present study, however, there were no (e.g., gender), arrest characteristics (e.g., rhythm), and reports to LAC EMS of either negligence by paramedics EMS factors (e.g., base station), those without signs of or emotional harm to family members attributable to the irreversible death were somewhat more likely to have new policy. In fact, this has remained the case in the nearly three years since the policy implementation.9 resuscitation attempts forgone under the new policy. In the target population of patients whose family made a verbal DNR request, or who met the new clinical criteria (lack of cardiac activity, plus time to resuscitation more Results From the LAC Policy Change than ten minutes), there was a small but noteworthy Quantitative and qualitative results from the LAC policy increase in forgoing attempted resuscitation. change were both positive. There was a modest but significant drop in the resuscitation attempt rate following An unexpected finding following implementation of the the change.10 And EMS personnel implementing the new policy was a significant decrease in reports of signs of policy in the field were almost unanimous in expressing irreversible death, from 50.4 percent to 35.8 percent. This an improved level of decision-making comfort and decrease may reflect, in part, some differences in patient empowerment under the new guidelines. Notably, too, and EMS factors during the study periods. Additionally, the change was implemented without any reports from given the magnitude of this reported decrease, it seems family members of adverse consequences resulting from likely that paramedics changed how they document the new policy, though the ability to investigate this issue clinical findings in the field as a response to the new policy itself. Under the previous policy, resuscitation In a Heartbeat: New Resuscitation Protocol Expands EMS Options  |  3 family members, EMS personnel and agencies, and the Paramedics Continue to Rely on Considered Judgment public. Many of them also expressed the belief that over Although the new LAC policy for EMS cardiac arrest time they will develop even more confidence and comfort patients permits paramedics to forgo resuscitation with the new guidelines. efforts in a wider variety of circumstances than did the previous policy, the paramedics themselves made clear to researchers that they continue to rely on their One of the points made by a number of paramedics was experience and considered judgment in making the how much they appreciate the way in which the verbal decision whether to forgo resuscitation efforts if there is DNR aspect of the policy permits them to respond to the no documentation of patient wishes. They asserted that wishes and needs of distraught families. One paramedic they will continue to attempt resuscitation when there is no DNR wish expressed and the clinical circumstances described such an encounter: indicate there is a reasonable chance for a positive outcome. As one paramedic put it during the course of We got a call about an unconscious male in full arrest. a focus group following implementation of the policy, When we get there, the family is in tears. They said, “If there’s any chance at all that they’re viable patients, “We’re looking for the DNR. We don’t have it.” There then we’re going to work on them.” Another spoke for the group, from which there was no dissent: “I think were three family members present. Everybody’s got everybody here would agree if it’s someone [with no the same thought and that’s good enough for us. written or family-expressed DNR] who has a chance, We don’t need the paper… It really worked out nice we’re going to resuscitate.” because there was a lot of stress and worries. They were trying to be with their family member at the same time trying to look for this paper…That’s where the new attempts were required unless there was either a valid policy comes in. written DNR at the scene or clear evidence of irreversible death. Paramedics may have decided to forego attempted Similarly, several paramedics spoke about how the new resuscitation when they believed that it would be policy encourages improved communication with family unsuccessful, then documented the circumstances as and other caregivers, which can make their experience “irreversible death.” Under the new policy, paramedics at least a bit less traumatic regardless of whether there can rely on a family verbal request or more liberal clinical is a verbal DNR. As one paramedic described such an criteria to forgo resuscitation efforts, permitting them to experience: practice — and to record their practice — more accurately and honestly. This, in turn, could be a boon to their job We received a textbook call about a man in cardiac satisfaction and a mitigation of their burnout rate, as arrest and citizen CPR was in progress. When we suggested by the enthusiastic reception paramedics have arrived at the man’s home his live-in nurse was given to the policy change. extremely upset so I took her to the back room to talk. I think one of the great things about this policy is Qualitative Changes Under the New Policy that it really helps people deal with the situation. For Perhaps the clearest result from the change in LAC them it’s a rollercoaster ride: “Here comes the lifesavers EMS resuscitation policy is the level of satisfaction with that are going to save my loved one, take him to the the new guidelines as expressed by the paramedics who hospital, and all is going to be good.” We know that’s implement it.11 In the focus groups conducted for this not the case. With the policy in place we can talk more project, EMS personnel had an overwhelmingly positive candidly with them and it works really well. We can set view of the new policy, feeling that it benefitted patients, them up for what is to be expected. 4  |  California HealthCare Foundation Also, though paramedics operate under more specific Special Circumstances May Dictate guidelines with the new policy than previously, the Resuscitation or Transport majority of paramedics considered the new policy Location of the patient, the presence of onlookers, or empowering, not restricting. “Before this policy,” one the absence of another responding agency (police or coroner) are circumstances that may call for attempted paramedic explained, “we were working them up because resuscitation and transport despite policy guidelines to that’s what it says … so you were bound to do those the contrary. One such circumstance is when a body things.” Now, the paramedics feel freer to consider not is in public view. Another is when family members do only the patient’s unwritten choice but also to act on a not seem emotionally prepared for paramedics to leave the body on the scene. In these instances, paramedics more realistic assessment — based on the new clinical and EMTs agreed that that it is appropriate to attempt characteristics — of the likely outcome of attempted resuscitation and/or to transport the deceased to a resuscitation. hospital emergency department despite policy guidelines that would otherwise encourage no attempted Paramedics expressed particular relief that the new policy resuscitation or transport. allowed them to act more discerningly in nursing homes Several paramedics mentioned the presence of the when forgoing resuscitation efforts clearly appeared to public, and particularly children, as such a factor: “I had one guy on a tennis court who went down and be the proper response. Several paramedics also noted his buddy was doing CPR. It was a public place where how much time and effort was involved in unwarranted people were coming to use the courts. There were kids resuscitation attempts under the previous policy, when around so he had to be transported. You almost have resources could be better used for other patients. As one to transport them because of the public impression on you.” Another paramedic described a situation where veteran paramedic put it, “Up until now, all the years the patient’s elderly spouse was alone and no other we’ve done this, it’s been so futile. It’s not worth the time agency responded, leading to a situation in which the and effort, and it comes up again and again. This last shift paramedics chose to engage in lengthy resuscitation we were working on a cardiac arrest; meanwhile so many attempts despite their assessment that, under the new policy, continuing such attempts was unnecessary: “It calls are coming in that we can’t handle that are probably was awkward because of the situation. We had to drag more viable patients.” her out from the bedroom into the living room because it was a small area. We had intubated her and had lines While praise for the new policy was almost universal in her. The husband was there by himself so we were among the paramedics who discussed it with researchers, there for well over an hour. We didn’t want to leave him there alone with his wife by himself.” one paramedic did express a different opinion: “It’s better for the family to see you work on their loved one,” this paramedic contended. “You are leaving a lasting impression in their minds that you’ve done everything you Implications and Challenges possibly could to bring this person back [even though] we The lessons learned from the LAC EMS resuscitation know, based on experience, that there’s probably no hope policy change may be encouraging and instructive to bring this person back.” This opinion stood alone, to other EMS systems considering a similar change. however, with all the other paramedics asserting that it The overall experience of the LAC EMS system and was better to give family realistic expectations than to its personnel regarding the change was almost entirely provide false hope. positive. However, attention to related issues could help make the new policy operate even more smoothly, and more study is needed to determine the potential costs and benefits brought about by the change. In a Heartbeat: New Resuscitation Protocol Expands EMS Options  |  5 A Family Verbal DNR Policy Can Provide EMS Dynamics with Police, Coroner, and Several Significant Benefits Emergency Departments to Be Addressed The new LAC resuscitation policy’s allowance of The focus groups in this project noted some tensions paramedics in the field to act on an immediate family between EMS providers, police, and coroner regarding member’s verbal DNR assertion yielded positive results how best to utilize their respective resources concerning in several respects. First, it contributed to a small patients in the field. The sometimes long wait before reduction in the number of attempted resuscitations, police arrived meant that paramedics had to remain and without any reports by paramedics of forgoing on the scene, providing no service other than a cordon resuscitation efforts when the paramedic’s judgment around the body and some company for the family, if would have dictated otherwise.12 Even more clearly, it present. This problem was compounded by paramedics contributed to improvements in the complex experience not being permitted to summon the coroner until the of both paramedics and family members. EMS personnel police arrived. To increase efficient use of EMS personnel almost universally expressed a decrease in stress owing and equipment, better resource allocation coordination to their ability to honor the wishes of immediate family among EMS, police, and coroner needs to be addressed. members. They also reported that family members, too, were relieved by the ability to have the patient’s Paramedics also reported occasional friction with wishes acted upon. Importantly, the policy also opened emergency department (ED) physicians over resource communication between paramedics and on-site family utilization. Under the previous LAC policy, paramedics members, which relieved anxiety for both regardless of the would have to transport to the ED many cardiac arrest attempted resuscitation decision. patients for whom there was nothing for the ED doctors to do. The new policy clearly offers the potential to New Clinical Characteristics May Lead to reduce such transports to the ED, which may result in a More Accurate and Honest Reporting reduction in unnecessary ED costs (see “Fiscal Impact of The inclusion in LAC’s policy of new clinical Policy Change,” below). characteristics which permit a paramedic to forgo attempted resuscitation had the unanticipated result Bereavement Training to Meet the Changing of contributing to a change in paramedics’ reporting. Paramedic Role Paramedics can and do now report that some decisions to While almost all paramedics in this study had a positive forgo attempted resuscitation were based on a medically overall response to the new policy, not all of them sound assessment — relying not on “irreversible death” but found it easy to carry out. The myriad issues around on other observed clinical criteria supported by the new leaving a body on the scene, rather than transporting policy — that such an attempt would have been highly it, were clearly part of the difficulty. Among these unlikely to result in a positive outcome. In addition to issues were family members’ disagreements and their relieving the emotional burden on paramedics of having perceived readiness to accept death. To the extent that to stretch their reporting of irreversible death, this change the new policy results in a combination of greater may result in the LAC EMS system being able to track direct engagement with family on the scene and fewer more accurately the nature of patient circumstances and transports, paramedics may spend more time with paramedics’ responses to them. grieving families. Effective bereavement training could increase the comfort level of paramedics, helping them embrace the new policy and their somewhat different role within it. 6  |  California HealthCare Foundation Los Angeles County Provides a Template for Other EMS Systems The experience of LAC EMS in preparing, implementing, and assessing its new field resuscitation policy may help other county EMS systems that are considering a similar change. LAC EMS worked with physicians and other academic medical researchers at UCLA to develop and evaluate the policy change. When another county’s EMS medical control committee meets to consider new protocols, policies, or procedures related to pre-hospital attempted resuscitation, it can look to and in some aspects rely on this LAC experience. • Experts Defined Best Practices. In the LAC project’s early stages, a panel of experts identified patient categories for which it was appropriate and feasible to forego resuscitation efforts. These experts included academic and practicing emergency physicians, paramedics, a trainer (nurse) of paramedics, a medical ethicist, a clergy member, and an attorney with expertise in end-of-life legal issues. The experts arrived at a set of indicators for forgoing resuscitation attempts and a process by which those indicators were to be acted upon in the field. Other county EMS systems would be able to consider such best practices without having to repeat fully this costly and time-consuming process. • Indicators Developed into Detailed Written Policy. The new LAC EMS policy is not inherently specific to LAC and can serve as a model for other EMS systems, to be modified as needed by a local EMS medical control committee in consultation with its base hospital and pre-hospital provider representatives. (The LAC written policy can be found in this brief’s Appendix B, with the new elements in Section I, Parts C3 and C5.) • Marketing to Paramedics. The LAC project included an organized campaign to introduce paramedics to the new policy. Because of LAC’s enormous size, this campaign was conducted only with the Los Angeles City Fire Department (LACF), the largest LAC EMS agency. The campaign included identifying local opinion leaders within the LACF and extensively engaging with them about the new policy. Also, all LACF paramedics were provided with simple graphic explanations of the new policy and were invited to participate in small group and one-on-one informational sessions. Paramedics outside LACF were provided with EMS policy written updates plus a video that details policy changes. • Quantitative Analysis. LAC’s quantitative analysis provides solid evidence to other EMS systems that the policy change resulted in a reduction in resuscitation attempts in the target population. Importantly, the data also show that the change was not so great as to raise fears that the new policy undermined longstanding EMS consensus about resuscitation practice. • Qualitative Analysis. The overwhelmingly positive response to the new policy by LAC paramedics can be extremely useful to a medical control committee in presenting a proposed policy change to representatives of its pre-hospital providers. • No Harm. EMS systems considering a resuscitation policy change can find confidence in the fact that despite the enormous size of the LAC EMS system, there were no reports of harm to patients or to patient families attributable to the new policy during the period studied by this project. Fiscal Impact of Policy Change this may work against the agency’s inclination to reduce It was beyond the scope of the present project to study the rate of attempted resuscitation and transport. On the fiscal impact of the new EMS resuscitation policy, but the other hand, the freeing-up of an agency’s resources issues related to costs and benefits are worth examining. when no attempted resuscitation or transport occurs may One question is whether there is a difference in payments offset such a reduction in payment, particularly if there is from the county to individual EMS agencies for field improved coordination with police and coroner. responses when paramedics attempt resuscitation and/ or transport, and when they do not. If an EMS agency Another site of potential fiscal impact is the ED. If there receives significantly less reimbursement for a response are fewer transports, there will be fewer interventions by when it does not attempt resuscitation and transport, EDs. This may affect the ED’s operational costs, which In a Heartbeat: New Resuscitation Protocol Expands EMS Options  |  7 may in turn affect payments from programs such as About the Authors Medicare and Medicaid, as well as from county medical Corita Grudzen, M.D., M.S.H.S., and Steven Asch, M.D., systems. M.P.H., were the principal investigators who worked with William J. Koenig, M.D., medical director of Los Angeles County Emergency Medical Services, to develop, implement, Conclusion and evaluate the new pre-hospital resuscitation policy. LAC EMS has joined a small but growing number of EMS systems that address two difficult situations regularly Corita Grudzen is an assistant professor in the Departments encountered by their paramedics when responding to a of Emergency Medicine and Geriatrics and Palliative Medicine cardiac arrest in the field: (1) A family member on the at Mount Sinai School of Medicine in New York City. Her scene verbally requests DNR in accordance with patient work on this project began when she was a Robert Wood wishes but without an available DNR document; and Johnson Clinical Scholar at the University of California, Los Angeles. Her current work as a Brookdale Leadership in (2) A patient is found in nonshockable rhythms after Aging Fellow is to develop a sustainable model for emergency prolonged down time without CPR, who is therefore department-based palliative care service delivery. highly unlikely to survive neurologically intact. By implementing a new resuscitation attempt policy, LAC Steven Asch is a health policy analyst at RAND and a EMS now permits its paramedics to make decisions professor of medicine at the University of California, Los congruent with patient wishes and with a clinically Angeles and the Department of Veterans Affairs’ (VA) Greater sound assessment of the likelihood of neurologically Los Angeles Healthcare System. His research focuses on application of quality measurement systems to improve care intact survival. Implementation of the new policy, during delivery, particularly in the areas of communicable disease an initial six-month study period, was received by the and end of life. Dr. Asch directs a national center for HIV system’s paramedics with almost universal approval and and hepatitis quality improvement research, as part of the VA resulted in a small but significant reduction in attempted Quality Enhancement Research Initiative. resuscitations without any reports from family members to EMS of negative consequences. Working on the project with Drs. Grudzen, Asch, and Koenig were W. John Boscardin, Ph.D., Jerome R. Hoffman, M.D., M.A., Karl A. Lorenz, M.D., M.S.H.S., Stefan Timmermans, Implementation of the new policy was not entirely Ph.D., and Jacqueline M. Torres. without challenges, and better coordination among responding agencies (EMS, police, coroner), as well as added bereavement training to help them meet their changing role with families, could improve paramedics’ About the F o u n d at i o n experience. Nonetheless, the overwhelming success of the The California HealthCare Foundation is an independent new policy in large and demographically complex Los philanthropy committed to improving the way health care Angeles, following the foundational work of LAC EMS is delivered and financed in California. By promoting and its UCLA partners in developing a protocol for its innovations in care and broader access to information, our introduction, suggests that similar policy changes by other goal is to ensure that all Californians can get the care they EMS systems may be relatively simple to achieve and very need, when they need it, at a price they can afford. For more likely to meet with a comparable level of success. information, visit www.chcf.org. 8  |  California HealthCare Foundation Appendix A: Methodology Qualitative Comparison of This study of the changes in the LAC EMS cardiac Paramedics’ Experience arrest resuscitation policy was comprised of two basic Following analysis of the run sheets for the six-month components. The first was quantitative, comparing post-change period, researchers for this study conducted reporting of resuscitation attempt rates over comparable a series of focus groups with EMS paramedics and periods before and after policy implementation. The Emergency Medical Technicians (EMT) who had second was qualitative, assessing paramedics’ own provided responses to cardiac arrests in both the perspectives on the policy change. The study was not pre-change and post-change study periods. The EMS without certain limitations, however, including a lack personnel were asked to discuss factors they used to of direct observation by researchers and an inability to decide on attempted resuscitation and transport both discuss individual events with the families involved. pre- and post-change in the policy. The EMS personnel also discussed barriers to full implementation of the new Quantitative Comparison of Resuscitation policy, as well as their personal experiences and levels of Attempt Rates satisfaction with the policy change. Finally, they were Following each field response, an LAC paramedic unit asked to comment on how the new policy was received completes and files an EMS Report, also known as a “run by their superiors, their colleagues, and patients’ family sheet.” Researchers for this study first examined these members. run sheets for a six-month period before implementation of the new policy, to determine location of the cardiac Study Limitations arrest, existence of a DNR, presence of a family member, Although researchers were able to analyze both the condition of the patient upon EMS arrival, and whether change in resuscitation attempt rates and paramedics’ resuscitation was attempted. The results of this analysis personal assessment of their work under the new policy, showed that the majority of prehospital cardiac arrests the present study did have some limitations. First, occurred at home, often in the presence of a family due to logistic and legal barriers, there was no direct member, but without a written DNR being produced.13 observation by researchers of paramedics in the field. Even if a DNR was present, it was often not followed. Such direct observation might have illuminated process This suggested that implementation of the new policy changes generated by the new policy that the paramedics might allow considerably more EMS consultation themselves were not sufficiently aware of to raise during with family members concerning the patient’s choice focus group discussions. Similar barriers also prevented concerning resuscitation efforts. follow-up discussions with patient family members, which might have provided additional evidence of how Researchers then studied the run sheets for a comparable the change in policy permitted paramedics to follow six-month period after implementation of the new patient wishes, and of the level of family satisfaction with resuscitation policy. Results were calculated for the paramedic response under the new policy. likelihood of foregoing resuscitation attempts and for the proportion of patients for whom signs of irreversible death were documented. An adjusted rate for foregoing resuscitation attempts was then calculated, which accounted for patient demographics, clinical characteristics, and EMS factors, and which excluded patients with signs of irreversible death. In a Heartbeat: New Resuscitation Protocol Expands EMS Options  |  9 Appendix B: Los Angeles County EMS Policy re Determination/Pronouncement of Death in the Field Those portions of the policy that were changed effective July 1, 2007, and discussed in this brief, are to be found in Section I, Parts C(3) and C(5). DEPARTMENT OF HEALTH SERVICES COUNTY OF LOS ANGELES SUBJECT: DETERMINATION/PRONOUNCEMENT (EMT-I/PARAMEDIC/MICN) OF DEATH IN THE FIELD REFERENCE NO. 814 PURPOSE: This policy is intended to provide prehospital personnel with parameters to determine whether or not to withhold resuscitative efforts and to provide guidelines for base hospital physicians to discontinue resuscitative efforts and pronounce death. AUTHORITY: California Health and Safety Code, Division 2.5 California Probate Code, Division 4.7 California Family Code, Section 297-297.5 DEFINITIONS: Agent: An individual, eighteen years of age or older, designated in a power of attorney for health care to make health care decisions for the patient, also known as “attorney-in-fact”. Immediate Family: The spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient. Conservator: Court appointed-authority to make health care decisions for a patient. Advanced Health Care Directive (AHCD): A written document that allows an individual to provide health care instructions or designate an agent to make health care decisions for that person. AHCD is the current legal format for a living will or Durable Power-of- Attorney for Health Care (DPAHC). PRINCIPLES: 1. Resuscitative efforts are of no benefit to patients whose physical condition precludes any possibility of successful resuscitation. 2. EMT-Is and paramedics may determine death based on specific criteria set forth in this policy. 3. Base hospital physicians may pronounce death based on information provided by the paramedics in the field and guidelines set forth in this policy. 4. If there is any objection or disagreement by family members or prehospital personnel regarding terminating or withholding resuscitation, basic life support (BLS) resuscitation, including defibrillation, should continue or begin immediately and paramedics should contact the base hospital for further directions. EFFECTIVE: 10-10-80 PAGE 1 OF 5 REVISED: 2-1-07 SUPERSEDES: 7-1-03 APPROVED: ______________________ ________________________ Director, EMS Agency Medical Director, EMS Agency 10  |  California HealthCare Foundation SUBJECT: DETERMINATION/PRONOUNCEMENT REFERENCE NO. 814 OF DEATH IN THE FIELD POLICY: I. Determination of death, base hospital contact not required: A. A patient may be determined dead if, in addition to the absence of respiration, cardiac activity, and neurologic reflexes, one or more of the following physical or circumstantial conditions exist: 1. Decapitation 2. Massive crush injury 3. Penetrating or blunt injury with evisceration of the heart, lung or brain 4. Decomposition 5. Incineration 6. Pulseless, non-breathing victims with extrication time greater than fifteen minutes, where no resuscitative measures can be performed prior to extrication. 7. Blunt trauma patients who, based on paramedic’s thorough patient assessment, are found apneic, pulseless, and without organized EKG activity* upon the arrival of EMS at the scene. *Organized EKG activity is defined as narrow complex supraventricular. 8. Pulseless, non-breathing victims of a multiple victim incident where insufficient medical resources preclude initiating resuscitative measures. 9. Drowning victims, when it is reasonably determined that submersion has been greater than one hour 10. Rigor Mortis (Requires assessment as described in Section I. B.) 11. Post-Mortem Lividity (Requires assessment as described in Section I. B.) B. If the initial assessment reveals rigor mortis and/or post-mortem lividity only, EMT-Is and/or paramedics shall perform the following assessments to confirm the absence of respiratory, cardiac, and neurologic function for determination of death in the field: NOTE: Assessment steps may be performed concurrently. 1. Assessment of respiratory status: a. Assure that the patient has an open airway. b. Look, listen and feel for respirations. Auscultate the lungs for a minimum of 30 seconds to confirm apnea. PAGE 2 OF 5 In a Heartbeat: New Resuscitation Protocol Expands EMS Options  |  11 SUBJECT: DETERMINATION/PRONOUNCEMENT REFERENCE NO. 814 OF DEATH IN THE FIELD 2. Assessment of cardiac status: a. Auscultate the apical pulse for a minimum of 60 seconds to confirm absence of heart sounds. b. Adults and children: Palpate the carotid pulse for a minimum of 60 seconds to confirm absence of pulse. c. Infants: Palpate the brachial pulse for a minimum of 60 seconds to confirm absence of pulse. 3. Assessment of neurological reflexes: a. Check for pupil response with a penlight or flashlight to determine if pupils are fixed and dilated. b. Check and confirm unresponsive to pain stimuli. C. Patients in atraumatic cardiopulmonary arrest, who do not meet the conditions described in Section I. A., require immediate BLS measures to be initiated while assessing or one or more of the following: 1. A valid Do Not Resuscitate (DNR) 2. A valid AHCD with one of the following present at scene: a. An AHCD with written DNR instructions. b. The agent identified in the AHCD requesting no resuscitation. 3. Immediate family member present at scene: a. With a Living Will or DPAHC on scene requesting no resuscitation. b. Without said documents at scene, with full agreement of others if present, requesting no resuscitation. 4. Parent or legal guardian is required and must be present at scene to withhold or terminate resuscitation for patients under 18 years of age. 5. Patient in asystole without CPR and the estimated time from collapse to bystander CPR or EMS initiating BLS measures is greater than 10 minutes. NOTE: If one or more of the conditions in Section I. C. is met, BLS measures may be discontinued and the patient is determined to be dead. PAGE 3 OF 5 12  |  California HealthCare Foundation SUBJECT: DETERMINATION/PRONOUNCEMENT REFERENCE NO. 814 OF DEATH IN THE FIELD II. Patients in cardiopulmonary arrest requiring base hospital contact. A. Pediatric patients (equal to or less than 14 years of age) who do not meet Section I. A., of this policy should receive immediate BLS measures while establishing base contact. B. Base contact shall be established for all patients who do not meet the conditions described in Section I. of this policy. The following are general guidelines: 1. Continuing resuscitation on scene is appropriate for patients in medical cardiopulmonary arrest until there is a return of spontaneous circulation (ROSC). 2. Transporting patients without ROSC is discouraged. C. Base hospital physician pronouncement of death: The base hospital physician may pronounce death when it is determined that further resuscitative efforts are futile. Patients without ROSC after 20 minutes of resuscitative efforts by EMS personnel should be considered candidates for termination of resuscitation. Exceptions may include hypothermia or patients who remain in, or whose rhythm changes to V-fibrillation or Pulseless V-tachycardia. III. Crime scene responsibility, including presumed accidental deaths and suspected suicides: A. Responsibility for medical management rests with the most medically qualified person on scene. B. Authority for crime scene management shall be vested in law enforcement. To access the patient(s), it may be necessary to ask law enforcement officers for assistance to create a “safe path” that minimizes scene contamination. C. If law enforcement is not on scene, prehospital care personnel should attempt to create a "safe path" and secure the scene until law enforcement arrives on scene. IV. Procedures following pronouncement of death: A. The deceased should not be moved without the Coroner’s authorization, any invasive equipment (i.e., intravenous line, endotracheal tube) used on the patient should be left in place. NOTE: If it is necessary to move the deceased in the event, the scene is unsafe or the deceased is creating a hazard, prehospital personnel may relocate the deceased to a safer location or transport to the most accessible receiving facility. PAGE 4 OF 5 In a Heartbeat: New Resuscitation Protocol Expands EMS Options  |  13 SUBJECT: DETERMINATION/PRONOUNCEMENT REFERENCE NO. 814 OF DEATH IN THE FIELD B If the patient is confirmed by law enforcement or the Coroner not to be a coroner’s case and the personal physician is going to sign the death certificate, any invasive equipment used during the resuscitation may be removed. C. Prehospital personnel should remain on scene until law enforcement arrives, during this time when appropriate, the provider should provide grief support to family member(s). D. Consider Critical Incident Stress Debriefing for all involved prehospital personnel for unusual cases or upon request. V. Documentation shall include: A. For patients determined to be dead, document the criteria utilized for death determination, condition, location, and position of the patient and any care provided. B. If the deceased was moved, the location and the reason why. If the Coroner authorized movement of the deceased, document the coroner's case number (if available) and the coroner’s representative who authorized the movement. C. For patients on whom base hospital contact is initiated, time of pronouncement and name of the pronouncing physician must be documented. Paramedics should provide a complete description of the circumstances, findings, medical history, and estimated duration of full arrest. D. The name of the agent identified in the AHCD or immediate family member who made the decision to withhold or withdraw resuscitative measures shall be documented along with their signature on the EMS report form. E. If the patient was determined not be coroner’s case and the patient’s personal physician is going to sign the death certificate, document the name of the coroner’s representative who authorized release of the patient and patient’s personal physician signing the death certificate, and any invasive equipment removed. CROSS REFERENCE: Prehospital Care Policy Manual: Ref. No. 518, Decompression Emergencies/Patient Destination Ref. No. 519, Management of Multiple Casualty Incidents Ref. No. 606, Documentation of Prehospital Care Ref. No. 806, Procedures Prior to Base Contact Ref. No. 808, Base Hospital Contact and Transport Criteria Ref. No. 815, Honoring Prehospital Do-Not-Resuscitate (DNR) Orders Ref. No. 818, Honoring Advanced Health Care Directives (AHCD) Ref. No. 819, Organ Donor Identification PAGE 5 OF 5 14  |  California HealthCare Foundation Endnotes 6.Grudzen, C.R., et al. 2009. “Potential Impact of a Verbal Prehospital DNR Policy.” Prehospital Emergency Care 13 1.Of the approximately 400,000 nontraumatic (not a (2); 169 – 72. secondary result of traumatic injury) cardiac arrests per year in the United States, the majority occur in what is 7.Feder, S., R.L. Matheny, R.S. Lovelace, Jr., and T.D. Tea. termed a prehospital setting: at home, at work or in a 2006. “Withholding Resuscitation: A New Approach to public place, or in a nursing home. Gilman, J.K., S. Jalal, Prehospital End-of-Life Decisions.” Annals of Emergency and G.V. Naccarelli. 1994. “Predicting and Preventing Medicine 144 (9); 634 – 40. Sudden Death from Cardiac Causes.” Circulation 90; 8.Mengual, R.P., M.J. Feldman, and G.R. Jones. 2007. 1083 – 92. “Implementation of a Novel Prehospital Advance Directive 2.In California at the time of this study, an enforceable Protocol in Southeastern Ontario.” Canadian Journal of patient choice not to be resuscitated could be formalized Emergency Medicine 9 (4); 250 – 259. in either of two types of documents: a separate DNR 9.California HealthCare Foundation interview with William document, or an advance health care directive authorized J. Koenig, M.D., medical director, Los Angeles County under California Probate Code §4701. For purposes of Emergency Medical System, March 9, 2010. discussion in this brief, the term DNR is meant to include either of these documents. As of January 1, 2009, a DNR 1 0.The fact that the increase in forgoing resuscitation was patient choice could also be included in a Physician Order small indicates that the new policy did not result in any for Life-Sustaining Treatment (POLST). unwanted or unanticipated radical changes in paramedic behavior. 3.Eckstein, M., S.J. Stratton, and L.S. Chan. 2005. “Cardiac Arrest Resuscitation Evaluation in Los Angeles: 1 1.The experiences and views of paramedics who CARE-LA.” Annals of Emergency Medicine 45; 504 – 9; implemented the new LAC policy are thoroughly Stueven, H., P. Troiano, B. Thompson, et al. 1986. explored in Grudzen, C.R., et al.. 2009. “Paramedics and “Bystander⁄First Responder CPR: Ten Years’ Experience in Emergency Medical Technicians Views on Opportunities a Paramedic System.” Annals of Emergency Medicine 15; and Challenges When Forgoing and Halting Resuscitation 707–10; Herlitz J., J. Engdahl, L. Svensson, M. Young, in the Field.” Academic Emergency Medicine 16 (6); K.A. Angquist, and S. Holmberg. 2004. “Can We Define 532 – 38. Patients with No Chance of Survival after Out-of-Hospital 1 2.The study was unable to determine how much of the drop Cardiac Arrest?” Heart 90; 1114 – 8. in the attempted resuscitation rate was attributable to the 4.Lockhart, L.K., P.H. Ditto, J.H. Danks, K.M. Coppola, new verbal DNR policy and how much to the new clinical and W.D. Smucker. 2001. “The Stability of Older Adults’ characteristics guideline. Judgments of Fates Better and Worse than Death.” Death 1 3.Grudzen, C.R., et al. 2009. “Potential Impact of a Verbal Stud. 25; 299 – 317; Ditto, P.H., J.A. Druley, K.A. Moore, Prehospital DNR Policy.” Prehospital Emergency Care 13 J.H. Danks, and W.D. Smucker. 1996. “Fates Worse than (2); 169 – 72. Death: The Role of Valued Life Activities in Health-State Evaluations.” Journal of Health Psychology 15; 332 – 43. 5.The definition of irreversible death remained the same under both the earlier policy and the changed policy, and includes the absence of respiration, cardiac activity, and neurologic reflexes, plus at least one other physical condition or circumstance. (See Appendix B.) In a Heartbeat: New Resuscitation Protocol Expands EMS Options  |  15